Preparing for a COVID-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in Singapore Se pre parer ...
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Can J Anesth/J Can Anesth
https://doi.org/10.1007/s12630-020-01620-9
REVIEW ARTICLE/BRIEF REVIEW
Preparing for a COVID-19 pandemic: a review of operating room
outbreak response measures in a large tertiary hospital
in Singapore
Se préparer pour la pandémie de COVID-19: revue des moyens
déployés dans un bloc opératoire d’un grand hôpital tertiaire au
Singapour
Jolin Wong, MBBS, MMed (Anaes), FANZCA . Qing Yuan Goh, MBBS, MMed (Anaes), EDIC .
Zihui Tan, MB ChB, MMed (Anaes) . Sui An Lie, MBBS, MRCP, MMed (Anaes) .
.
Yoong Chuan Tay, MBBS, MMed (Anaes) Shin Yi Ng, MBBS, MMed (Anaes), EDIC, PGDip (Clinical Ultrasound),
FCCP, FCCM, FAMS . Chai Rick Soh, MBBS, MMed (Anaes), FANZCA, CICM
Received: 2 March 2020 / Revised: 4 March 2020 / Accepted: 4 March 2020
Ó Canadian Anesthesiologists’ Society 2020
Abstract The coronavirus disease 2019 (COVID-19) workflow. We also discuss how the hierarchy of controls
outbreak has been designated a public health emergency can be used as a framework to plan the necessary measures
of international concern. To prepare for a pandemic, during each phase of a pandemic, and review the evidence
hospitals need a strategy to manage their space, staff, and for the measures taken. These containment measures are
supplies so that optimum care is provided to patients. In necessary to optimize the quality of care provided to
addition, infection prevention measures need to be COVID-19 patients and to reduce the risk of viral
implemented to reduce in-hospital transmission. In the transmission to other patients or healthcare workers.
operating room, these preparations involve multiple
stakeholders and can present a significant challenge. Résumé L’épidémie liée au coronavirus 2019 (COVID-19)
Here, we describe the outbreak response measures of the a été qualifiée d’urgence de santé publique de portée
anesthetic department staffing the largest (1,700-bed) internationale. La préparation face à une pandémie
academic tertiary level acute care hospital in Singapore nécessite de la part d’un hôpital l’élaboration de
(Singapore General Hospital) and a smaller regional stratégies pour gérer ses infrastructures, ses processus,
hospital (Sengkang General Hospital). These include son personnel et ses patients; il doit notamment instaurer
engineering controls such as identification and des mesures de prévention des infections pour réduire la
preparation of an isolation operating room, transmission intrahospitalière. Pour un bloc opératoire,
administrative measures such as modification of workflow ces préparations impliquent la participation de nombreux
and processes, introduction of personal protective acteurs et peuvent constituer un véritable défi. Nous
equipment for staff, and formulation of clinical guidelines décrivons les mesures prises en réponse à l’épidémie par
for anesthetic management. Simulation was valuable in le département d’anesthésie qui sert le plus grand hôpital
evaluating the feasibility of new operating room set-ups or universitaire de soins aigus (1700 lits) de Singapour
(Singapore General Hospital) et un plus petit hôpital
régional (Sengkang General Hospital). Cela a été obtenu
JolinWong, MBBS, MMed (Anaes), FANZCA (&)
grâce à des expertises d’ingénierie, telles que
Q. Y. Goh, MBBS, MMed (Anaes), EDIC Z. Tan, MB ChB,
MMed (Anaes) S. A. Lie, MBBS, MRCP, MMed (Anaes) l’identification et la préparation d’une salle d’opération
Y. C. Tay, MBBS, MMed (Anaes) S. Y. Ng, MBBS, MMed en isolation, des mesures administratives telles que la
(Anaes), EDIC, PGDip (Clinical Ultrasound), FCCP, FCCM, modification du déroulement des activités et des processus,
FAMS C. R. Soh, MBBS, MMed (Anaes), FANZCA, CICM
l’introduction d’équipements de protection individuels
Division of Anaesthesiology, Singapore General Hospital,
Outram Road, Singapore 169608, Singapore pour le personnel et — enfin — la formulation de lignes
e-mail: jolin.wong@singhealth.com.sg directrices cliniques pour la gestion anesthésique. La
123
J. Wong et al.
simulation a été importante pour évaluer la faisabilité de China.7 During the SARS outbreak in 2003,
toutes nouvelles modifications des salles d’opération ou anesthesiologists also contracted SARS in the line of
d’un nouveau flux de travail. Dans le contexte des duty.25 With the institution of infection control measures,
différentes phases d’une pandémie, nous discutons de several hospitals successfully operated on patients with
l’application d’une hiérarchie de contrôles comme cadre SARS without any transmission of SARS-CoV within the
des modifications à chaque niveau de contrôle et nous operating room complex.26,27
passons aussi en revue les données probantes soutenant les The Division of Anesthesiology at SGH developed
mesures prises. Ces mesures de confinement sont disease outbreak response measures in coordination with
nécessaires pour optimiser la qualité des soins procurés surgical, nursing, and other allied health staff. The two
aux patients atteints de COVID-19 et pour réduire le risque goals of these measures were to facilitate the care of
de transmission du virus à d’autres patients ou employés patients with known or suspected COVID-19 who needed
du domaine de la santé. surgery, and to reduce the risk of perioperative viral
transmission to healthcare workers and other patients. At
the time of writing, no patients with COVID-19 have
required surgery, but we expect this to change in the near
On 30 January 2020, the World Health Organization future as the number of cases increases globally.
(WHO) declared the severe acute respiratory syndrome This article aims to describe the measures taken to
coronavirus 2 (SARS-CoV-2) outbreak a public health address these goals, including identification and set-up of
emergency of international concern.1 Human-to-human an isolation operating room (OR), modification of
transmission of SARS-CoV-2 was established and at the workflow and processes, management of staff, and
time of writing this article, it has caused coronavirus formulation of clinical guidelines for anesthetic
disease (COVID-19) in over 90,000 people in 72 countries, management.
with a case fatality rate of 2.3% in China and 1.6% outside
China.2–8
Singapore General Hospital (SGH) confirmed Hospital measures related to surgery and anesthesia
Singapore’s first case of COVID-19 on 23 January
2020.9,10 Local transmission was subsequently reported11 Increasing capacity
and by 7 February 2020, Singapore raised the Disease
Outbreak Response System Condition (DORSCON) alert To cope with the anticipated increased influx of COVID-19
level to orange, indicating that the disease is severe and patients, we decided to reduce elective surgery.28 Day
spreads easily from person to person (but is not spread surgery, cancer surgery, and other urgent operations
widely and is being contained).12,13 continued as normal. We increased the turnaround time
Current understanding of SARS-CoV2 transmission is between elective surgeries to accommodate additional
based on extrapolation from past experience with the infection prevention measures.
SARS-CoV outbreak in 2003.14–17 Possible modes of
transmission include respiratory droplets, contact, fomites, Management of patients, visitors, and staff
and the fecal-oral route.18,19 At present, there is no
conclusive evidence of airborne transmission of SARS- All patients presenting to the hospital were screened using
CoV-2, but past experience suggests that SARS-CoV can a standard questionnaire. Patients who fulfilled the criteria
be transmitted via aerosol-generating procedures, most for suspected SARS-CoV-2 infection were isolated,
commonly tracheal intubation.20,21 As with most referred to an infectious diseases specialist, and tested for
respiratory viruses, it is considered most contagious when the virus. Elective surgery was postponed if the patient had
the patient is symptomatic, but SARS-CoV-2 has been travelled to affected areas. Visitor numbers were also
transmitted by asymptomatic individuals.22 Early data restricted.28
suggests that transmissibility of SARS-CoV-2 is Staff were asked to refrain from unnecessary travel to
moderate, with a basic reproduction number of certain destinations as advised by the Singapore Ministry
approximately 2.23,24 of Health.29 Staff returning from these destinations were
Transmission within healthcare facilities to healthcare required to take a 14-day leave of absence. We also
workers has been documented: 3.8% of COVID-19 cases separated staff caring for COVID-19 patients and those
have occurred in healthcare workers, causing five deaths in caring for other patients to reduce the risk of in-hospital
123
COVID-19 and the operating room
transmission. Staff who had cared for COVID-19 patients Operating room management
continued with usual clinical work with a surgical mask on
and monitored themselves for fever and respiratory An OR with a negative pressure environment is ideal to
symptoms. If inadequate personal protective equipment reduce dissemination of the virus beyond the OR.5,30 A
(PPE) was worn at the time of close contact, the staff standard OR is usually designed to be at positive pressure
member was taken off duty while an infectious diseases relative to surrounding air. Nevertheless, a high frequency
team assessed the risk of transmission and planned of air changes (25 per hr) rapidly reduces viral load within
subsequent management. Temperatures of all staff were the OR.
taken twice daily using hospital-issued oral digital A small OR complex comprising three separate ORs
thermometers, and entered into electronic records was designated for surgery in patients suspected or
monitored by administrative personnel. Web-based forms confirmed to have COVID-19. This was separate from
were created to facilitate ease of entry using personal the main OR complex and reduced the risk of
smartphones. Staff members who developed a fever or contaminating other ORs and other patients. Elective
respiratory symptoms were screened at the staff clinic. surgeries on non-COVID-19 patients were relocated to
the main OR complex. Each OR had its own ventilation
Communications and staff support system with an integrated high-efficiency particulate air
(HEPA) filter. Traffic and flow of contaminated air were
In the early phase of the outbreak, the situation was rapidly minimized by locking all doors to the OR during surgery,
evolving so case definitions and hospital guidelines were with only one possible route for entry/exit via the scrub
modified frequently. Communication channels including a room.
COVID-19 website were set up and daily email updates New workflows were created for activation and use of
were sent to all staff. Staff used social media, such as the designated isolation OR. These workflows considered
Workplace from Facebook and encrypted instant coordination of staff, movement of surgical and anesthetic
messaging, to approach senior management with ideas or equipment, infection prevention practices, and
concerns.13 decontamination following the procedure. An additional
Resources, including reading material and a helpline, anesthesiologist was called in to care for the COVID-19
were set up in the hospital to help staff cope with COVID- patient, while the usual on-call specialist continued with
19-related anxiety and burnout.13 emergency surgery in the main OR.
Fig. 1 Personal protective equipment donning and doffing areas. Step 2: Donning PAPR (B). Step 3: Enter OR through scrub room.
Steps are colour-coded (A: blue for clean and red for contaminated) Step 4: Clean external surface of the PAPR face shield (C), remove
and marked in numerical sequence at designated areas just outside the surgical gown and outer gloves. Step 5: Doffing PAPR (D). OR =
OR, with posters to guide staff on the process. Step 1: Put on N95. operating room; PAPR = powered air-purifying respirator
123
J. Wong et al.
Because more time is needed to prepare for surgery in a visits were also postponed. Pregnant and immunocompromised
suspected/confirmed case of COVID-19, daily routines staff did not care for patients with COVID-19.
were set up regardless of whether surgery would happen.
These included routine checks and cleaning of anesthetic
machines and powered air-purifying respirator (PAPR) Measures for infection prevention
sets. Designated areas were prepared for donning and
doffing of PPE. Steps were numbered in sequence and Routine infection prevention measures
posters were put up to guide staff (Fig. 1).
Once community spread of the virus had been confirmed, the
hospital instituted guidelines for airborne and contact
Management of staff in the division of anesthesiology precautions during all aerosol-generating procedures.
These included wearing N95 masks, eye protection, gown,
Personal protective equipment and gloves. Routine care of low-risk patients (no fever or
respiratory symptoms, no history of recent travel or close
A comprehensive program for the use of PPE was enforced. contact with a COVID-19 patient) required only the use of a
Healthcare personnel were medically cleared and trained in the simple surgical mask to protect against droplet transmission.
use of PPE. They were also taught how to clean, disinfect, store,
and inspect their PPE for any damage. All staff were fitted with Infection prevention when caring for the COVID-19
the National Institute of Occupational Safety and Health patient
(NIOSH)-certified N95 respirators. If staff did not fit into
available N95 masks, they would use the CleanSpaceR The minimum standard of PPE for any staff caring for a
HALOTM PAPR (CleanSpace Technology Pty Ltd, patient with confirmed/suspected COVID-19 infection is a
Artarmon, NSW, Australia). Personal goggles (model 9302- fitted, NIOSH-certified N95 respirator, eye protection
245; Uvex, Germany) were also issued to every member of (either goggles or full-face shield), cap, gown, and
staff. gloves.5 Double gloves may be considered and the outer
pair should be changed when contaminated.31 As
Powered air-purifying respirator training transmission remains possible despite N95 protection,32
staff participating in aerosol-generating procedures can
Refresher training for the use and maintenance of the PAPR wear a PAPR (Fig. 2).
was conducted. Educators from the Department of The patient, wearing a surgical face mask, should be
Occupational and Environmental Medicine trained transported from the isolation unit along a designated route
designated trainers within the department who then went with minimal contact with others.31
on to train the 180 anesthesia staff members (consultants and Only selected equipment and drugs should be brought
trainees) on the Jupiter and Proflow PAPR models (3M, St into the OR to reduce the number of items that need
Paul, MN, United States of America). In addition, mask cleaning or discarding following the procedure.33 Single-
fitting was done for all users of the CleanSpaceR HALOTM. use equipment should be selected where possible.26
Consent and charting are done electronically with touch-
Segregation of staff screen devices to facilitate decontamination. Anesthetic
monitors, laptop computers, and ultrasound machine
The anesthesia division staffs a tertiary hospital (SGH) and a surfaces are covered with plastic wrap to decrease the
smaller regional hospital (Sengkang General Hospital). Staff risk of contamination and to facilitate cleaning (Fig. 3).
were segregated between the two to reduce cross infection The patient should be reviewed, induced, and recovered
between hospitals. Locum employment and large group within the OR itself to restrict contamination to just one
meetings were suspended. Web-based conferencing was used room.27 The number of staff involved in the surgery should
to enable communication. Attendance was taken at all face-to- be limited.5 Movement of staff in and out of the OR should
face meetings to facilitate contact tracing should the need arise. also be restricted.31
After surgery, the anesthetic breathing circuit and the
Minimizing exposure and spread canister of soda lime are discarded to eliminate the negligible
risk of circuit contamination.25,26,34 After disposing of single-
Routine postoperative visits were suspended and replaced by use equipment in well-marked biohazard bags, all instruments
phone calls where applicable to reduce movement of staff are sent for decontamination and sterile reprocessing.
around the hospital. Non-urgent preoperative assessment clinic Surfaces of all medical devices are cleaned with quaternary
ammonium chloride disinfectant wipes. The OR is then
123
COVID-19 and the operating room
Fig. 2 Staff in powered air-
purifying respirator (PAPR)
during an aerosol-generating
procedure
Fig. 3 High-touch equipment
within the operating room are
wrapped with plastic sheets to
facilitate decontamination. A)
Anesthesia workstation. B)
Back of anesthesia workstation.
C) Exposed surfaces wrapped
with plastic. D) Laptop for
nursing documentation
123
J. Wong et al.
cleaned with sodium hypochlorite 1000 ppm and treated with technique is chosen, the patient should wear a surgical
hydrogen peroxide vaporization or ultraviolet-C irradiation. face mask at all times.5 If sedation is administered,
All staff then shower and change into a clean set of scrubs. supplemental oxygen may be administered via nasal
Names of all participating staff members are recorded to prongs underneath the surgical mask.25 Non-invasive
facilitate contact tracing. More time is needed for positive pressure ventilation and high flow nasal cannulae
decontamination, so the turn-around time following surgery such as the transnasal humidified rapid-insufflation
is increased. ventilatory exchange should be avoided to reduce the risk
of viral aerosolization.
Before anesthesia induction, a HEPA filter should be
Anesthesia of patients with suspected/confirmed connected to the patient end of the breathing circuit, and
COVID-19 another between the expiratory limb and the anesthetic
machine.33 Equipment should be prepared to reduce the
A study of 1,099 patients with COVID-19 showed that need for circuit disconnections—e.g., any circuit
18.7% present with shortness of breath, 41.3% require extensions should be attached before starting the case. A
oxygen supplementation, 5% become critically ill, and definitive airway with an endotracheal tube is preferred
2.3% require invasive mechanical ventilation.35 The over a supraglottic airway device because it has a better
median duration of symptoms and hospital length of stay seal. A video-laryngoscope is recommended because a
are both between 12 and 13 days.10,35 To reduce risks to PAPR hood or goggles may hamper vision during direct
both patient and staff, only emergency and not elective laryngoscopy. A video-laryngoscope also keeps the
surgery should be performed on COVID-19-infected intubator further from the patient’s airway during
patients.33 If a few hours’ delay is permissible, it is intubation.36
preferable to await the results of the viral swab before Pre-oxygenation should be carried out via a well-fitting
proceeding. In patients confirmed to have COVID-19 who face mask.25 Rapid sequence induction should be carried
require urgent surgery (e.g., cancer or cardiac surgery), the out to reduce the need for bag-mask ventilation.25 If bag-
risks and benefits of proceeding or postponing need to be mask ventilation cannot be avoided, small tidal volumes (at
weighed. low pressure) should be administered.25 Deep anesthesia
A team huddle should take place before surgery to and neuromuscular blockade should be achieved before
ensure everyone understands the plan for anesthesia and attempting intubation, and the latter can be assessed by
surgery. This enables seamless teamwork and ensures that train-of-four monitoring. Ensure full expiration into the
all necessary drugs and equipment have been prepared. It face mask before lifting it off the patient’s face. The most
also minimizes the need to leave and re-enter the OR to experienced operator should intubate.25 Following
bring in missing equipment. All staff should be aware that intubation, the cuff should be inflated and the circuit
communication is more difficult after PPE (and especially connected before initiating positive pressure ventilation.
PAPR) have been donned, and pay special attention to Closed, in-line tracheal suction should be used instead of
facilitate communication during the procedure.26 All staff open suction.33 Minimizing circuit disconnections is ideal,
should be protected in appropriate PPE, and the staff but if this is unavoidable, ensure positive pressure
number should be restricted to the minimum necessary for ventilation is ceased, turn the adjustable pressure limiting
patient safety.5 Given the relative lack of familiarity with valve to zero, and consider clamping the endotracheal tube
the new changes in workflow, an OR coordinator is prior to disconnection. This technique may also be used
assigned to each team caring for the COVID-19 patient. before switching a patient from intensive care from the
This coordinator directs all team members and guides them transport ventilator to the anesthetic machine. The patient
on their roles and infection prevention measures. A core should be preoxygenated and the duration of disconnection
group of anesthesiologists, who are familiar with the should be kept to a minimum to avoid exacerbating
isolation OR processes, serve as coordinators. hypoxia in critically ill COVID-19 patients with respiratory
Anesthesia should be planned with two goals in mind: failure.
patient safety and infection prevention. Infection Anti-emetics should be administered to reduce
prevention entails reducing aerosol-generating procedures postoperative retching. A rigid suction catheter may be
(i.e., airway manipulation, face mask ventilation, open used to reduce the chance of contaminating the
airway suctioning, patient coughing) as far as possible.33 surroundings with the soft flexible suction catheter. All
Regional anesthesia is preferred over general anesthesia. equipment in contact with patient secretions should be
Awake intubation techniques should be avoided because carefully manipulated. This includes the suction device,
both patient coughing and atomized local anesthetic may endotracheal tube, nasogastric tube (if used) and even the
lead to aerosolization of the virus.25,33 If a regional tape used to cover the eyes. Following extubation, the
123COVID-19 and the operating room
patient should wear a surgical face mask. Supplemental neonatal teams, simulation is conducted to familiarize all
oxygen may be administered via nasal prongs underneath the staff with the planned workflow.
the face mask.25 Venturi masks should be avoided as they
may aerosolize the virus.25 The patient should recover Cardiothoracic surgery
within the OR itself.
The National Heart Centre Singapore (NHCS) performs all
elective cardiac surgery within its own OR complex, which
Considerations specific to individual disciplines is connected to the main SGH building via a link bridge.
Emergency surgeries done after office hours are usually
Interventional radiology (IR) performed in the major OR complex in the main SGH
building. To isolate known/suspected COVID-19 patients
As far as possible, portable cases that can be done under requiring emergency cardiac surgery, the largest OR within
local anesthesia should be done so in the isolation ward the outbreak OR complex was chosen. This accommodated
within the airborne infection isolation room (AIIR).28 If the additional equipment such as the cardiopulmonary bypass
procedure requires anesthetic support, it should take place machine, intra-aortic balloon pump, transesophageal
in the isolation OR. If the procedure is more complex and echocardiography machine, and fluid management
requires specialized equipment such as a computed system. Because the main NHCS operating complex was
tomography scan, it should take place in a dedicated further away, equipment such as a dedicated bypass
room within the IR facility with its own control room. machine and other essential cardiac equipment such as
As the IR suite is regularly used for procedures, it would cell saver, cerebral oximetry, fluid warmer, and disposable
have to be cleared and prepared for a patient with COVID- bronchoscope were stored in the isolation OR complex.
19. This would mean postponing or cancelling other The use of a heated humidifier was discouraged to avoid
elective procedures and discharging any patients viral aerosolization.
recovering within the post-anesthetic care unit. Equipment kits for peripheral arterial and central venous
Unnecessary equipment should be removed from the cannulation were assembled and contained all necessary
procedure room. Remaining equipment (such as image items such as syringes and gauze (Fig. 4). This was done to
intensifier, lead shield) should be covered with plastic reduce contamination of common equipment stores. To
sheets. Signs are placed at doors to alert other staff not to familiarize cardiothoracic anesthetic staff with the new set-
enter the room without PPE. up in the isolation OR, they were given photographs
A similar workflow can be replicated as in the isolation showing the location of essential drugs and equipment.
OR with similar principles of reducing exposure of staff,
ensuring appropriate PPE, reducing contamination, and
subsequent decontamination. All processes from pre- In situ simulation
induction checks to recovery should be done within the
procedure room.27 In situ simulation was important for testing the
preparedness of our isolation OR and procedures. In situ
Obstetrics simulation is simulation training that takes place in the
actual clinical environment. It has been used to improve
Current limited evidence suggests that there is no reliability and safety in high-risk or high-stress
vertical transmission of the virus to the neonate if the environments,40–42 and has been shown to improve
mother is infected in late pregnancy.37 Considerations clinical skills, teamwork, patient safety, and behaviour.43
specific to obstetrics include protecting the neonate and We conducted a series of simulations and ‘‘walk-throughs’’
preventing transmission of the virus. In theory, a lower of various scenarios with different surgical disciplines. The
segment Cesarean delivery may reduce fecal-oral final scenario involved a crisis situation that required the
transmission, but this is may not be favoured because surgical and anesthesia participants to perform
it has more risks.38 resuscitation while wearing PPEs and PAPRs. The
Cesarean deliveries should be performed in the isolation objectives of these simulations were to proactively seek
OR if the mother is a known or suspected COVID-19 latent threats and potential breaches in infection control,
patient. At birth, the neonate should be isolated and be especially during vulnerable and stressful moments of
cared for by a dedicated neonatal team in a separate room crisis. We also wanted to evaluate the responsiveness of
from the mother.38,39 We use the induction room for this our activation workflow and adaptability of the isolation
purpose as it has the necessary oxygen supply and suction OR to cater to a variety of surgeries. These simulation
apparatus. If this environment is unfamiliar to obstetric and exercises allowed us to identify and address unexpected
123J. Wong et al.
potentially compromise patient and staff safety were not
missed. By rectifying deficiencies, we were able to
effectively improve OR responsiveness and readiness by
streamlining the ward transport process and refining the OR
activation workflow. This was reflected in faster activation
times with each in situ simulation.
Discussion
As part of disease containment measures, our anesthetic
division implemented the above procedures in phases to
decrease the risk of SARS-CoV2 transmission. In the initial
phase, the emphasis was on identifying and isolating
imported cases. Once local community transmission had
been reported, surveillance was enhanced to identify cases,
including cases with no previous travel to affected areas or
previous contact with infected persons. At that stage,
routine PPE was also enhanced in case of undiagnosed
COVID-19. However, if there is widespread global
transmission, containment will no longer be feasible and
the goals will shift towards risk mitigation instead, to
reduce the impact on society.44,45
Containment measures may be categorized according to
the hierarchy of controls approach,46 which has been used
to effectively control exposure to occupational hazards
Fig. 4 Pre-packed sets of equipment (Fig. 5).
To control exposure to infectious diseases in the
problems that were not apparent in the initial planning, healthcare environment, options for hazard control, such
such as lack of oversight and coordination, environment as elimination and substitution controls, are often limited
limitations, unsatisfactory equipment set-up, or not feasible. Nevertheless, transmission of respiratory
communication difficulties, lack of familiarity with pathogens (such as SARS-CoV2) can often be reduced
protective equipment, infection control breaches, and through exposure control by means of engineering,
inadequate support during crisis. These led to many administrative controls, and PPE.5,28 Figure 6 shows the
downstream interventions, including appointing an OR summary of the measures adopted.
coordinator to oversee this multi-step and multidisciplinary Engineering controls refer to the placement of barriers
activation process to ensure that essential steps that may between the hazard and healthcare personnel. Ideally, AIIR
Fig. 5 Hierarchy of controls to
control exposure to
occupational hazards. The five
layers can be implemented
concurrently or sequentially. To
control exposure to infectious
diseases in the healthcare
environment, elimination and
substitution controls are often
limited or not feasible.
Effectiveness of control
measures generally decreases
down the layers
123COVID-19 and the operating room
Fig. 6 Summary of the measures implemented in the operating room and anesthetic department to enhance infection prevention in a COVID-19
pandemic
should be used as ORs for surgical patients who had were used whenever possible to decrease the risk of virus
airborne infections.28 Nevertheless, in our institution, all exposure to OR sterile processing technicians. HEPA filters
the ORs are positive pressure rooms and we did not have were used at the patient’s end of the breathing circuit and
AIIR which could be used as ORs. Therefore, a separate also between the expiratory limb of the circuit and the
OR complex was set aside for surgery involving COVID- anesthetic machine to decrease the risk of environmental
19 patients. Disposable anesthetic and surgical equipment contamination.
123J. Wong et al.
Administrative controls refer to policies mandated by Respiratory Protection Standards, all healthcare personnel
healthcare institutions to reduce or prevent exposure to were trained on the indications and proper use of PPE.
hazards. One of the first policies implemented was to Twenty percent of anesthesiologists in our division
discourage unnecessary travel to high-risk areas affected failed fit-testing for N95 respirators (1860, 1860S, 1870?
by COVID-19, and to impose a leave of absence upon by 3MTM [3M, St Paul, MN, USA]), increasing the risk of
return from these areas. It is likely that travel restrictions in them becoming infected should they be exposed.52
China over the Chinese New Year holiday limited the Alternative respiratory protection should be made
spread of infections.7,47 In the first few weeks of the available to these staff, or they should be allocated duties
outbreak, cases outside China emerged in Bangkok, Hong away from high-risk areas. This has implications on
Kong, and Singapore—all cities with high volumes of air anesthetic departments in particular, as our routine work
traffic from China.48 COVID-19 infections diagnosed in six involves aerosol-generating procedures. Staff who failed to
countries were traced back to one single conference.49 At be fitted for the N95 respirator may use the PAPR instead.
least one medical conference in Singapore was cancelled In our department, they were fitted for a PAPR with a
because of transmission risk. facepiece (CleanSpaceR HALOTM). This offers better
Other administrative controls in the hospital protection than a hooded PAPR with a loose fitting
environment include the screening and isolation of high facepiece.53 Sufficient PAPR devices should therefore be
risk patients. Location-based segregation of staff was available to cater for different operational and staffing
implemented and large group meetings were suspended needs and advance consideration must be given to
to reduce potential cross-infection among healthcare purchasing additional sets. Furthermore, eye protection is
personnel. In a pandemic, should the numbers of important because inoculation of the conjunctival surface
COVID-19 patients increase dramatically, OR staff may result in COVID-19 infection5,54,55 Goggles were
should be segregated into those caring for infected therefore issued to each member of staff.
patients and those caring for other patients, to reduce the There is risk of a shortage of N95 respirators during any
possibility of in-hospital transmission.28 Anesthetic pre- pandemic, especially if it becomes prolonged. Measures
assessment, induction, and postoperative recovery of each taken to mitigate this included earlier mentioned
patient should be conducted in a single OR with restricted engineering and administrative controls to decrease the
staff numbers.28 In situ simulation was invaluable in number of healthcare personnel requiring respiratory
helping us identify latent threats and gaps in workflow. It protection. Alternatives such as PAPRs may be used and
allowed members of the operating team to understand the practices may be introduced to extend the use of each N95
challenges of operating in an unfamiliar environment with respirator. The latter include extended use and limited re-
additional PPE, and allowed us to identify unexpected use.56 Extended use refers to the practice of wearing the
deficiencies that were not apparent in the initial planning same N95 respirator for repeated close contact encounters
stage. Together with other authors who have used with several patients, without removing the respirator
simulation-based training to prepare for disease between patient encounters. Studies have shown that most
outbreaks,50,51 we highly recommend it to refine healthcare personnel could tolerate wearing N95
processes, enhance communication, and build staff respirators for up to eight to 12 hr.57,58 Nevertheless,
confidence. because most healthcare workers need to take breaks
Personal protective equipment is the final line of during shifts to eat, drink, and use the toilet, extended use
protection for healthcare workers especially in the of N95 beyond four hours is unlikely in most settings.59
context of community transmission, as patients without Re-use refers to the practice of using the same N95
known contact history may also be carriers of the virus. In respirator for multiple encounters with patients but
line with Occupational Safety and Health Administration removing it after each encounter. The Association for
Professionals in Infection Control and Epidemiology
Table 1 Recommended practices for extending the use and/or re-using an N95 respirator
Avoid removing, adjusting, or touching the respirator (both outside and inside surfaces)
Discard the respirator if it becomes grossly contaminated or damaged or if breathing through it becomes difficult
Perform hand hygiene before and after handling/touching the respirator
Store the respirator in a clean, dry location to avoid contamination and maintain its integrity. It can be stored in a single-use breathable container,
or hung in a designated area
Inspect the respirator and perform a seal check before each use
123COVID-19 and the operating room
position paper, developed from various guidelines touch their eyes, face, or mucous membranes as these may
(including the United States Centers for Disease Control lead to self-contamination. In our institution, trainers from
and Prevention, Food and Drug Administration, the Infection Control and Occupational Medicine
Occupational Safety and Health Administration, WHO departments were initially overwhelmed by requests to
and the Institute of Medicine), recommend extended use conduct PAPR training. To mitigate this, we arranged for
over re-use.60 these trainers to teach and test a small group of anesthetic
For cases with highly suspected or confirmed COVID- consultants on the correct use of PAPR. This group then
19 infection, we adopted a single-use policy for these went on to teach all 180 staff in the division.
respirators because extended use and limited re-use of Powered air-purifying respirators have a higher
these respirators carries risks, such as droplet spray protective factor than N95 respirators,63 but there is no
contamination, degradation of filtration efficacy and mask conclusive evidence to show that PAPRs decrease the
fit with time, cross-contamination during storage, and likelihood of viral transmission, especially airborne
contamination during doffing and donning of the transmission.36 The concurrent use of N95 respirators
respirators. with PAPR to further decrease the risk of viral transmission
Nevertheless, we adopted a re-use policy for N95 may sound tempting, but there is no strong evidence of an
respirators for cases with a low suspicion of COVID-19 added protective effect.64 Disadvantages of such
infection. The recommended practices for extending the concurrent use include increased communication
use and/or reusing a respirator can be found in Table 1.60 difficulties,65 claustrophobic reactions,66 and increased
This includes performing hand hygiene before and after risk of infection from doffing the additional layers of
handling of the respirator; inspecting and performing a seal PPE (Table 2).67 It is more important to emphasize proper
check before each use; avoiding the removal, adjustment, doffing and cleaning of PAPR for re-use to prevent
and contact with the inner and outer surfaces of the contamination and cross-infection.
respirator; storing it in a clean dry location to avoid A recent review of 22 studies revealed that human
contamination and to maintain its integrity; and discarding coronaviruses such as SARS-CoV, Middle East
the respirator if it is grossly contaminated or damaged or if Respiratory Syndrome (MERS) coronavirus, or endemic
breathing through it becomes difficult. human coronaviruses can persist (i.e., maintain viral
Training staff to use PPE competently is essential. In an morphology or ability to infect cells) on inanimate
observational study, 90% of staff did not use the correct surfaces such as metal, glass, or plastic for up to nine
doffing sequence or technique, or use the appropriate days. Nevertheless, these can be efficiently inactivated by
PPE.61 According to a survey conducted by Amrita John surface disinfection procedures with 62–71% ethanol, 0.5%
et al., 11 of 74 (14.9%) physicians did not have prior hydrogen peroxide or 0.1% sodium hypochlorite within
training in the use of PPE.62 Emphasis must be placed on one minute.68 Other biocidal agents such as 0.05–0.2%
proper doffing technique and staff must be reminded not to benzalkonium chloride or 0.02% chlorhexidine digluconate
Table 2 Pros and cons of powered air-purifying respirator (PAPR)
Pros Cons
Higher protective factor than N95 respirators No definitive evidence that PAPR reduces likelihood of viral
transmission for potential airborne infections
Provides eye protection (hooded models only) Inability to auscultate for heart and lung sounds (for hooded
PAPR)
More comfortable to wear than N95 respirator Challenges in communication
Can be used if user has facial hair (not possible with N95 respirator) Patient apprehension (especially among pediatric patients)
Hooded models do not require fit-testing (unlike N95 respirator) Training on use, doffing, and care of PAPR is needed to prevent
contamination
Eliminates unexpected poor N95 respirator fit Requires decontamination after use
Less likely to be dislodged when managing an agitated patient More expensive than N95 respirator
PAPRs with hood may provide additional protection against contamination Inability to re-use disposable filters between patients (need large
compared with typical gear worn with N95 mask supply of filters)
Need to train staff repeatedly to maintain competency if not
frequently used
Risk of battery failure and inadvertent exposure
123J. Wong et al.
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Conflicts of interest None. 14. World Health Organization. Q&A on coronavirus (COVID-19).
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Funding statement None. q-a-coronaviruses (accessed March 2020).
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Editorial responsibility This submission was handled by Dr. 19. Available from URL: https://www.ecdc.europa.eu/en/novel-
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